The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study

Sheppard, James P; Mellor, Ruth M; Greenfield, Sheila; Mant, Jonathan; Quinn, Tom; Sandler, David; Sims, Don; Singh, Satinder; Ward, Matthew; McManus, Richard J

doi:10.1136/emermed-2013-203026

Cited by 49 publications

(40 citation statements)

References 24 publications

(33 reference statements)

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“…ED principal diagnoses of "missed" cases were commonly descriptive rather than disease specific. Misdiagnosed patients were typically clinically assessed as FAST-negative [13], and having a less medically "urgent" condition (pertaining to a lower ED triage category) with a more prolonged time before undergoing CT or MRI brain imaging. Despite significantly less speech and motor deficits, which are important components of the National Institute of Health Stroke Scale, and predictive of a worse outcome, misdiagnosed stroke patients had lengths of stay and functional outcomes at discharge similar to the stroke control group [15].…”

Section: Discussionmentioning

confidence: 99%

“…Demographic data, premorbid modified Rankin Scale (mRS) score, vascular risk factors, clinical assessment of Face, Arm, Speech, Time (FAST) status [13], ED triage category, time to first CT and MRI brain, symptom duration (transient vs. persistent), clinical symptoms and signs including headache, altered mental status, dizziness, vertigo, nausea/vomiting, hemiparesis and dysarthria, first ED clinician contact, admitting team (neurology vs. non-neurology services) and stroke location were compared. Dizziness and vertigo were defined in accordance with the International Classification of Vestibular Disorders [14].…”

Section: Methodsmentioning

confidence: 99%

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Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

et al. 2018

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Background: Failure to recognise acute stroke may result in worse outcomes due to missed opportunity for acute stroke therapies. Our study examines factors associated with stroke misdiagnosis in patients admitted to a large comprehensive stroke centre. Methods: Retrospective review comparing 156 consecutive stroke patients misdiagnosed in emergency department (ED) with 156 randomly selected stroke controls matched for age, gender, language spoken and stroke subtype for the period 2014–2016. Results: There were 141 ischemic and 15 hemorrhagic misdiagnosed strokes (median age: 77 years, male:female = 1.3: 1). Symptom resolution, altered mental status, nausea/vomiting, dizziness and vertigo favored misdiagnosis (p < 0.05). Hemiparesis and dysarthria favored an accurate diagnosis (p < 0.05). Misdiagnosed patients were more commonly triaged into a lower ED category (62 vs. 42%, p = 0.001), clinically assessed as Face, Arm, Speech and Time (FAST) – negative (78 vs. 22%, p < 0.001) and underwent delayed CT imaging (median 4.1 vs. 1.5 h, p < 0.001). Misdiagnosed patients were more likely to have posterior circulation stroke (PCS; 39 vs. 22%, p = 0.01) and be admitted under non-neurological services (35 vs. 11%, p < 0.001) with worse discharge outcomes including increased mortality. Conclusions: Patients with stroke misdiagnosis were commonly FAST-negative with nonspecific symptoms including altered mental status, dizziness and nausea/vomiting often associated with PCS. Improved diagnostic accuracy may increase access to acute therapies.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

et al. 2018

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“…As a result, encouraging the public to activate EMS when stroke symptoms are recognized is a focal point of public education efforts for stroke [5] . Once initiated, accurate prehospital recognition of acute stroke and activation of in-hospital stroke response is critical to minimizing evaluation and treatment delays, as well as to promoting efficiency in prehospital systems of care [3,4,[6][7][8][9] . A number of validated screening tools have been developed to assist on-scene EMS providers in the recognition of stroke symptoms and signs [10] , and have been incorporated into EMS practice guidelines [5] .…”

Section: Introductionmentioning

confidence: 99%

Dispatcher Stroke Recognition Using a Stroke Screening Tool: A Systematic Review

et al. 2016

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Background: Emergency dispatchers represent the first point of contact for patients activating an acute stroke response. Accurate dispatcher stroke recognition is associated with faster emergency medical services response time; however, stroke is often unrecognized during initial emergency calls. Stroke screening tools such as the Cincinnati Prehospital Stroke Scale have been shown to improve on-scene stroke recognition and thus have been proposed as a means to improve dispatcher accuracy. We conducted a systematic review of the accuracy of emergency dispatcher stroke recognition when employing stroke screening tools. Methods: We conducted a comprehensive search of Medline, EMBASE, CINAHL, and Cochrane databases to identify studies of dispatcher stroke recognition accuracy. Those that specifically reported dispatcher utilization of any validated stroke screening tools in isolation or in the context of a comprehensive screening algorithm such as the Medical Priority Dispatch System (MPDS) were potentially eligible. Studies that reported data sufficient for calculation of dispatcher sensitivity or positive predictive value (PPV) using a hospital-based stroke/transient ischemic attack diagnosis as the reference standard were included. Two independent reviewers determined study eligibility, assessed quality using the QUADAS 2 instrument, and abstracted data. Results: We identified 1,413 potential studies; 54 underwent full text review. Three retrospective and 4 prospective cohort studies enrolling a total of 16,382 patients met the inclusion criteria. Stroke screening tools included MPDS (n = 4), Face Arm Speech Time (n = 2), and a novel screening algorithm developed after analysis of emergency calls for stroke (n = 1). Regardless of the screening tool employed, dispatcher stroke recognition sensitivity was suboptimal (5 studies, range 41-83%) as was the PPV (7 studies, range 42-68%). Primary study limitations included application of variable reference standards and questions regarding exclusion of subjects. No studies directly compared stroke screening algorithms and no studies specifically examined stroke recognition among potential candidates for acute stroke therapies. Conclusion: Even when utilizing a stroke screening tool, the accuracy of stroke recognition by emergency dispatchers was suboptimal. More research is needed to identify the causes of poor dispatcher stroke recognition and should focus on potential candidates for time-dependent stroke treatment.

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“…The Goals of Optimal Organization [21][22][23][24] It is important to insist on the following goals: -Offer this bi-therapy to a maximum number of patients. This target is important because almost 10% of ischemic stroke patients are eligible for rt-PA, and 15% of stroke patients eligible for rt-PA may benefit from MT.…”

Section: Resultsmentioning

confidence: 99%

“…In 2015, Sheppard et al [22] evaluated the relationship between time to the request for CT, time to first contact with the stroke team, the recording of onset time, stroke identification using the FAST test and sending of a prealert message. The study highlighted the importance of pre-alerting the hospital, accurate stroke identification and recording the onset time in making the right decision in acute stroke.…”

Section: The Tools To Reach These Objectivesmentioning

confidence: 99%

Impact of Mechanical Thrombectomy on the Organization of the Management of Acute Ischemic Stroke

et al. 2016

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Background: Several trials and meta-analyses have recently demonstrated the superiority of endovascular therapy over standard medical treatment in patients presenting with acute ischemic stroke. In order to offer the best possible treatment to a maximum number of patients, many stroke care networks probably have to be reorganized. After analyzing the reliability of data in the literature, an algorithm is suggested for a pre-hospital and in-hospital alert system to improve the timeliness of subsequent treatment: a drip-and-ship approach. Summary: Five recent well-designed randomized studies have demonstrated the benefit of endovascular therapy associated with intravenous fibrinolysis by recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke with confirmation by recent meta-analyses. The keys for success are a very short time to reperfusion, within 6 h, a moderate to severe pre-treatment deficit (National Institute of Health around 17), cerebral imaging able to identify proximal large vessel occlusion in the anterior circulation, a limited infarct core and a reversible penumbra, the use of the most recent devices (stent retriever) and a procedure that avoids general anesthesia, which reduces blood pressure. To meet these goals, every country must build a national stroke infrastructure plan to offer the best possible treatment to all patients eligible for intravenous fibrinolysis and endovascular therapy. The plan may include the following actions: inform the population about the first symptoms of stroke, provide the call number to improve the timeliness of treatment, increase the number of comprehensive stroke centers, link these to secondary and primary stroke centers by telemedicine, teach and train paramedics, emergency doctors and radiologists to identify the stroke infarct, proximal large vessel occlusion and the infarct core quickly, train a new generation of endovascular radiologists to improve access to this therapy. Key Message: After 20 years of rt-PA, this new evidence-based therapy is a revolution in stroke medicine that will benefit patients. However, a new robust and multi-disciplinary care strategy is necessary to transfer the scientific data into clinical practice. It will require reorganization of the stroke infrastructure, which will include comprehensive stroke centers and secondary and primary stroke centers. The winners will be patients with severe stroke.

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The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study

Cited by 49 publications

References 24 publications

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

Dispatcher Stroke Recognition Using a Stroke Screening Tool: A Systematic Review

Impact of Mechanical Thrombectomy on the Organization of the Management of Acute Ischemic Stroke

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